Other Factors Contributing to Suicide Risk

Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

The following risk factors (sometimes called "vulnerabilities") are also related to suicide risk.

Sixty percent of all suicides are committed by people with mood disorders. Mood disorders are a broad category of mental illness that includes major depression and bipolar disorder (an illness characterized by shifts between low levels of mood and energy to high levels of mood and energy), and other conditions including dysthymia (a long-term, low-grade level of depression), cyclothymia (a milder form of bipolar disorder) and schizoaffective disorder (an illness with a combination of psychotic thinking and mood problems).

People who are just emerging from a prolonged depressive episode are particularly at risk of committing suicide. There is little energy to plan and implement a suicide in the depths of depression. However, as depressive symptoms begin to lessen, more energy is available for planning. In addition, physical symptoms of depression, such as tiredness, frequently improver faster than cognitive symptoms, such as suicidal ideation. This means a person may have more energy to carry out self-destructive thoughts. Adding alcohol to the situation, which may also cloud thinking, significantly increases the suicide risk of people with mood disorders.

Approximately 30% of suicides are committed by people who have psychiatric disorders other than mood disorders. This number includes individuals with post traumatic stress disorder (PTSD, described later), schizophrenia, personality disorders, sleep disorders, eating disorders (particularly anorexia nervosa), and many other conditions. In total, some 90% of people who commit suicide have one or more diagnosable mental illnesses. People with psychiatric "co-morbidity" (i.e., individuals who have two diagnosable mental disorders occurring at the same time) are particularly at risk for suicide.

Psychiatric disorders are associated with a range of symptoms that can trigger suicidal ideation, planning and gestures. For example, psychotic disorders such as schizophrenia can be accompanied by hallucinations, such as voices, that may direct people to kill themselves. Other mental disorders can cause poor impulse control and a lack of judgment and perspective. Some patients turn to suicide as an escape from their seemingly unending symptoms. Others may turn to suicidal behavior in an effort to get and hold other people's attention, or to punish other people.

There is a significantly higher rate of suicide among people who abuse alcohol and/or drugs. Alcohol is involved in an estimated 30% of suicides. Alcohol causes a depressed mood, lowers inhibitions, and impairs judgment. Any or all of these may set up vulnerable people to act on suicidal plans. These same factors (lowered inhibition and impaired judgment) are also associated with domestic violence and abuse, which is another factor that increases the likelihood that suicide will occur.

Some suicides are the result of the side effects of prescription drugs, or combinations of prescription and recreational drugs. Certain drugs cannot be mixed safely, and many drugs do not mix safely with alcohol. A bad combination of drugs/medications or over-dose can be lethal. Knowing these possibilities, some people purposefully use combinations of drugs and medications against a doctor's advice as a means of committing suicide. Others accidentally kill themselves by this method.

People who have access to firearms are more likely to commit suicide.

Emotional insults, such as rejection, public humiliation or shame, may be experienced as painful enough by some people to push them towards suicide. Feelings of social rejection often lead to social isolation, which also increases suicidality. In addition, a combination of poor coping skills or other suicide vulnerability factors and an emotional insult can be particularly devastating. Current research suggests that young homosexual or bisexual males are at greater risk than heterosexuals for suicide attempts, but findings are less clear regarding suicide completion.

Survivor guilt caused by witnessing or experiencing torture, abuse, war/combat, genocide or other violence appears to be a cause of suicide in some cases. Survivor guilt occurs when someone survives a horrific situation, violent accident or combat situation, and is later overcome by feelings of guilt over the fact that they survived while others died or were injured. Survivors may become unable to forgive themselves for feeling relieved that they lived while others died. They may also start to think that they did not deserve to live while others died. Intense shame and guilt emotions can lead to suicidal ideation, gestures, or to self-injurious/parasuicidal behaviors. Survivor guilt and associated emotions can co-occur with PTSD, a condition characterized by flashbacks (traumatic memories), trauma-themed nightmares, extreme jumpiness, and difficulties managing emotions.

People who are terminally ill or have long-term, serious chronic illnesses, paralysis, disfigurement or loss of limbs sometimes commit suicide. People experiencing these conditions may commit suicide because of pain or discomfort related to their condition or its treatment, or due to grief surrounding the loss of functioning or appearance. Suicide may also be a method for avoiding the potential long-term emotional pain of slowly deteriorating or seeing loved ones struggle to cope with the dying process. Some people use suicide as an attempt to regain some control concerning when and how they will die, rather than feeling like the passive victim of an incurable medical condition. Others may commit suicide to avoid what they believe would be a complete, or near complete, lack of quality of life as a terminal condition progresses.

Significant grief and loss can also be associated with suicidality. Losing an important person, (such as a spouse, child, parent, friend or other significant relationship), a job, a treasured social role or status, financial assets, health, or something else of significance usually results in grief. Grief feelings are painful. They can easily become overwhelming, particularly in the short term when they are fresh, and then later on during anniversaries of the loss. People who've undergone significant loss may feel emotionally devastated and completely alone in the world. They may also feel like they do not have the emotional resources, coping skills, or social supports necessary to cope with grief. Significant loss can trigger an existential crisis state in which the grieving person cannot see any reason to continue living. Such feelings can be fairly common when passionate love affairs end abruptly. They can also occur when losses are more about social status and economic means rather than intimate affairs. For example, some people have committed suicide after stock market crashes in the wake of significant financial losses.

Grieving is a universal reaction, but there is great individual variability in how it is experienced. If you find yourself in a grief situation (and if you live long enough, it is certain that you will), give yourself the permission to grieve in the manner that you find most natural. More information about the grief process may be found in our Grief and Bereavement Topic Center.

People with a family history of suicidal behavior are more likely to attempt or commit suicide. Children learn how to cope through a process known as modeling. In essence, children are watching their parents and caregivers cope, and imitating what they see. Modeling is a powerful teaching tool, and the parent-child relationship is usually the most significant teaching-learning relationship experienced in a lifetime. A parent who attempts or completes suicide ends up accidentally modeling for their children that suicide is an acceptable method for coping with emotional pain or stressful situations. These childhood lessons about suicide can be replayed even when someone becomes an adult. Depending on people's pre-existing vulnerabilities and the importance they place upon a particular relationship, suicide by another family member, school teacher, coach or mentor may also set people up for suicide themselves.

People who commit or attempt suicide are sometimes copying an idol or famous case of suicide. In a copy-cat suicide, a person with identity issues who has become over-identified with an appealing or admired (sometimes famous) individual re-enacts his or her suicide. Sometimes, just finding out about a suicide (the method used or the circumstances) initiates copycat behavior in a vulnerable individual, because the individual was already feeling suicidal to begin with. Suddenly, the vulnerable individual is provided with a realistic suicide method and becomes convinced that he or she can follow through with the act. Repeated media coverage of the suicides of political/religious figures or celebrities may also initiate copycat suicides. Research suggests that youth are more likely to be influenced by media presentations of suicide and to die in cluster suicides (groups of suicides occurring in close proximity in terms of time and/or place) than other age groups.

People who are highly impulsive sometimes commit suicide. Some people are more impulsive than others, which is to say, they are more willing to act spontaneously and before they have had occasion to carefully think through the ramifications of their actions. Impulsive people are highly driven by rewards, but are less concerned with the punishing or negative consequences of their behavior. Cautious people, on the other hand, are more punishment-sensitive and less motivated by rewards. Because of their reward sensitivity, impulsive people are more willing than cautious people to engage in risky behavior; especially when that risky behavior has intense short-term rewards associated with it. Examples of such risky behavior might include unprotected, promiscuous sex, taking drugs, picking unnecessary fights, gambling, driving too fast, playing "chicken" with trains and "Russian Roulette" with loaded guns.

Impulsivity is a normal dimension of personality on which everyone varies. (see our discussion below on temperament). Some people are born being more impulsive than other people. However, impulsivity can also be caused by psychiatric disorders, brain injuries, and drugs and medications like Valium and alcohol.

Impulsivity may seem attractive in a person who is carefree, unpredictable, and full of fun and life. However, impulsivity can also lead people to make rash decisions, such as acting on suicidal impulses, without first carefully weighing the risks and benefits of those actions. Some highly impulsive people have histories of parasuicidal, violent, homicidal, or otherwise dangerous behavior which may also be associated with alcohol or drug use. However, it's often not until such a person completes a suicide or makes a significant suicide gesture that these behaviors come to be correctly viewed as warning signs.

People who've made other suicide attempts, gestures, or who have harmed themselves physically in other ways in the past are at higher risk of completing suicide than are other people who haven't done these things. Some people who survive an initial suicide attempt go on to make additional suicide attempts. People who have made prior suicide attempts are some 38x more likely to attempt suicide again in the future.

People who were abused or neglected as children have a higher risk of suicide than others. These children are sent lots of unhelpful messages that impair their sense of self-worth and ability to trust as adults. Victims of abuse or neglect may also fail to develop methods to cope with daily stresses or may develop a sense of hopelessness or helplessness to improve their lot in life. Still others may develop PTSD, a condition characterized by flashbacks (traumatic memories), trauma-themed nightmares, extreme jumpiness, and difficulties managing emotions.

Victims of domestic violence are at higher risk of suicide than people who have not had this experience. As is the case for childhood abuse and neglect, domestic violence may result in PTSD, emotional distress, and impaired coping skills. Many people in abusive relationships feel desperate and trapped - some enough so to attempt or commit suicide.

People involved in, or arrested for, committing crimes are at higher risk of committing suicide than other people. Most suicide victims in jails of all types and sizes (e.g., rural and urban county jails, city jails, and prisons) are young white males arrested for nonviolent offenses, intoxicated upon arrest, who subsequently hang themselves. It is difficult to know exactly why this is the case, as there are many variables that come into play. Though people with criminal records are more likely to commit suicide, they are also more likely to have personal histories including child abuse, and alcohol or substance abuse. Suicide may seem like a means of escaping punishment when the sentence for criminal behavior is lengthy, or involves significant prison time. Some inmates may also turn to suicide as a means of escaping rape at the hands of other prisoners. Many prison facilities have policies in place to try and prevent inmate suicidal behavior.

Having reviewed the significant risk factors and vulnerabilities that are linked to suicidal behavior, we now turn to discuss the contribution of stressful events and life circumstances that act to trigger suicidal ideation and behavior.